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Vision Rehabilitation Techniques for TBI

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Vision Rehabilitation Techniques for TBI Carl Garbus, O.D., FAAO Neuro Vision Rehabilitation Institute Valencia, CA Strategies for Light Sensitivity Turn off or avoid ... – PowerPoint PPT presentation

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Title: Vision Rehabilitation Techniques for TBI


1
Vision Rehabilitation Techniques for TBI
  • Carl Garbus, O.D., FAAO
  • Neuro Vision Rehabilitation Institute
  • Valencia, CA

2
Learning Objectives
  • Describe the incidence and prevalence of brain
    injury
  • Distinguish between acquired brain injury and
    traumatic brain injury
  • Identify basic brain structures and functions
  • Describe 2 main visual processes in the brain
  • Describe visual consequences of brain injury
  • Discuss assessments and interventions

3
Goals for the Presentation
  • Create awareness of what to look for in patients
    who have had traumatic brain injury
  • Stress the importance of having a neuro vision
    evaluation for patients with traumatic brain
    injury and stroke
  • Know that neuro vision rehabilitation exists for
    patients with these conditions

4
Definitions
  • Traumatic brain injury (TBI)
  • An insult to the brain, not of a degenerative or
    congenital nature but caused by an external
    physical force,
  • That may produce a diminished or altered state of
    consciousness.

5
  • Causes of TBI
  • Motor vehicle accidents - whiplash
  • Falls
  • Gunshot wounds
  • Work place injuries
  • Shaken baby syndrome
  • Child abuse
  • Sports injuries
  • Military actions

6
  • Different ways brain can be damaged

7
Neck Trauma
  • Whiplash
  • A simple whiplash can cause shearing of nerve
    fibers in the brain stem
  • This can occur from being rear ended by a car
    driving moving at 15 miles an hour
  • Disruption of fibers in the brainstem affects
    oculomotor and binocular functions.

8
Basic brain structures and functions
  • Lobes

9
  • " The eyes see only what the
  • mind is ready to comprehend"
  • Henri Bergson

10
Brain and vision the connection
  • Every lobe of the brain is involved in processing
  • visual information.
  • To date, researchers have identified over 300
    intracortical pathways linking 32 different
    cortical areas involved in vision function.
  • More than half of our gray matter and multiple
    subcortical areas are involved in processing
    vision.
  • There is more area of the brain dedicated to
    vision than to all the other senses combined.

11
The Visual Brain
12
Vision is a Bimodal System
  • There are 2 main pathways that carry visual
    information from the eye to the brain.
  • Focal - the "what" system
  • Ambient - the "where system"
  • Designed to simultaneously process different
    types of visual information
  • Neither works in isolation of the other both
    reinforce one another

13
Focal and Ambient Systems
  • Need to work in harmony
  • They are not isolated systems
  • A disconnect in the ambient
  • system will cause problems
  • with spatial orientation
  • Symptoms include balance problems, bumping into
    things, difficulty navigating

14
Five Pillars of Function
  • Visual
  • Physical / Vestibular
  • Somatosensory
  • Cognition
  • Psychosocial

15
Why is vision rehabilitation so important
following brain injury?
  • Vision is our dominant sense we are visual
    beings.
  • Vision is pervasive throughout our brain.
  • Vision is represented all over our body.
  • Vision influences and influenced by anything and
    everything - the way we think, say, or do.
  • Visual problems are among the most common
    consequences of TBI and or CVA but frequently not
    dealt within rehab model.

16
Visual Consequences of TBI Post Trauma Vision
Syndrome (PTVS)
  • A constellation of symptoms that evolves as
    secondary injury in TBI.
  • This syndrome is caused by a dysfunction of the
    ambient visual system and has the characteristics
    listed below
  • Binocular coordination dysfunctions - double
    vision
  • Inability to perceive spatial relationships
    between objects
  • Difficulty fixating on object and following when
    it moves
  • Abnormal posture
  • Dizziness and balance problems
  • Poor visual memory

17
Visual consequences of TBI Post Trauma Vision
Syndrome (PTVS)
  • Poor concentration and visual attention
  • Difficulty with visually guided movements
    (bumping/tripping, knocking things over)
  • Light sensitivity / photophobia
  • Visual midline shift syndrome
  • Visual spatial difficulties

18
  • Sense of balance
  • Bump into things
  • Difficulty with eating
  • Slow reading

19
What are the functional implications? Binocular
Dysfunction
20
  • Difficulty judging distance or depth
  • Tendency to knock things over
  • Bump or trip over obstacles
  • Difficulty playing sports

21
What are the functional implications? Visual
information processing
22
  • Avoidance of crowded or busy places
  • Short memory
  • Forget familiar route
  • Slow to process

23
Visual Midline Shift
  • Mismatch between the perceived egocentric
  • visual midline and the actual physical midline
  • Causes an expansion on one side
  • Causes a contraction on the opposite side

24
Visual Midline Shift Syndrome
  • Signs and Symptoms
  • Floor may appear tilted
  • Walls and/or floor may appear to shift and move
  • Veering during mobility
  • Person leans away from the affected side
  • Feelings of imbalance or disorientation similar
    to vertigo

25
Cranial Nerve VIII Auditory and Vestibular
Nerve
  • Nerve that transmits information for hearing and
    balance

26
Vestibular Function
  • The visual system links up very closely with the
    vestibular system in the brainstem and midbrain
  • Vestibular Ocular Reflex (VOR) is activated when
    there is a head movement, body movements or if
    the individual leans to one side

27
Vestibulo-Ocular Reflex
  • Maintenance of fixation of the eyes with head
    movements
  • It is activated with horizontal and vertical head
    movements
  • This intricate system links the vestibular system
    to the oculomotor system

28
Interventions
  • Patient education
  • Explain brain and vision relationship
  • Review individual's specific diagnosed eye
    condition in plain language
  • Why and how vision may be interfering or limiting
    daily functions.
  • Always include family members whenever possible

29
Interventions
  • Strategies
  • Relieve visual discomfort from eye strain and
    fatigue often leading to headaches.
  • Take care of those dry eyes!
  • Reduce glare and light sensitivity - very
    important!
  • Take frequent breaks from visually demanding
    tasks - 20/20/20 rule

30
Interventions
  • Limit use of computer and mobile devices
  • Recognize and avoid non visually- friendly
    reading materials
  • Use color filter overlays to reduce strobbing
    effect of black on white paper
  • Utilize adaptive tools to assist with visual
    stamina (magnifiers, Kindle, long cane)
  • Glasses need to be up to date
  • Lens is designed for the task

31
Interventions
  • Therapy
  • Safety first! OM training to improve viewing
    posture, balance, and stability, spatial
    awareness and relationships for interaction with
    environment with better accuracy. Long white
    cane training if field loss.

32
Strategies for Double Vision Techniques
  • Consult with an optometrist or ophthalmologist
    who has experience with brain injury
  • Provide a translucent patch (not dark opaque
    patch)
  • Spot patch
  • Sector patch
  • Binasals
  • Active therapy prescribed by the eye care
    practitioner can improve binocular function- Eye
    Stretches, Tactile Control, Spatial Localization,
    Brock String

33
Interventions
  • Prisms bends light towards the base, which
    causes the image to move in the opposite
    direction---- has implications to change spatial
    orientation and eye alignment
  • Lenses optical correction of refractive
    conditions helps to locate objects in space and
    helps with visual comfort
  • Filters blocks specific light frequencies that
    cause visual discomfort which can improve visual
    performance

34
Strategies for Light Sensitivity
  • Turn off or avoid fluorescent lighting
  • Increase exposure to natural lighting
  • Wear prescription sunglasses with Polaroid lenses
  • Consider side shields
  • Wrap around frames

35
Strategies for Light Sensitivity
  • Blue-tec lens filter (indoor)
  • Green-blue filter for use in areas where
    fluorescent lighting is unavoidable
  • Binasal occlusion
  • Light therapy program

36
Strategies for Disorientation and Dizziness
  • Grounding techniques
  • Thumb and forefinger stimulation
  • Proprioceptive input
  • Breathing technique

37
Strategies for Improving Mobility
  • Special prescription glasses specially designed
    to enhance mobility
  • Consult with an optometrist/ophthalmologist who
    has experience with brain injury and vision
    rehabilitation
  • Yoked prism lenses maybe useful in therapy or as
    a full time prescription
  • Binasals can provide grounding and reduce visual
    confusion
  • Referral source is NORA

38
Yoked Prism Glasses
  • Special prism lenses prescribed by a
    rehabilitation eye doctor
  • Prisms bend light in a specific direction towards
    the base of the prism
  • Prisms can alter the patients visual spatial
    orientation and posture
  • Navigation can be improved over uneven or
    challenging surfaces

39
Yoked Prism Glasses
  • Demonstration
  • The Effect of Prisms for Mobility and Navigation

40
Strategies for Improving Mobility
  • During mobility training observe posture, arm
    swing, body alignment, balance, head position and
    turns
  • Observe visual balance
  • When balance is a problem use the technique of
    eyes leading the way before making turns
  • Obstacle Course procedures

41
Obstacle Course
  • Place 3 chairs approximately 3 feet apart
  • The patient is shown how to navigate around the
    chairs
  • Changing visual conditions for navigation
  • Adding visual stimulus to the sides
  • Adding auditory stimulus
  • Demonstration

42
Strategies for Visual Field Loss
  • Identify where the losses are located with visual
    field
  • Does it affect ambulation?
  • Does it affect reading?
  • --------------------------------------------------
    -------------
  • Trial Peli Prisms for hemianopsia
  • Trial yoked prisms
  • Improve scanning skills
  • Need single vision Rx glasses (distance and near)
  • Progressives limit peripheral visual field
    function

43
Strategies to Enhance Visual and Vestibular
Integration Specific Procedures
  • Head Rotations With Central Fixation
  • Chair Rotations
  • Body Rotations
  • Four Corner HART Charts
  • Side To Side HART Chart Rotations
  • GOALS better coordination of these systems can
    be accomplished by using vision to support
    vestibular

44
Summary
  • Consult with an vision rehabilitation doctor to
    collaborate about functional treatments
  • Consider visual conditions that can be treated
    such as light sensitivity, visual balance, visual
    midline shift and post trauma vision syndrome
  • Brainstem damage will have visual and vestibular
    consequences
  • Double vision is common problem that needs to be
    dealt with early

45
Summary
  • Good referral source is the Neuro Optometric
    Rehabilitation Association
  • Avoid crowded environments
  • Inquire about yoked prisms and binasal occlusion
  • Use the grounding techniques described in this
    course
  • Dont give up there are many solutions to improve
    the quality of life after a traumatic brain injury

46
Neuro Optometric Rehabilitation Conference
  • 24th Annual Multi-disciplinary Conference
  • Renaissance Hotel
  • May 14-17, 2015
  • Denver, CO
  • Website www.nora.cc
  • Email noraoptometric_at_yahoo.com
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